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PUBUC 
HEALTH 
LIBRARY 


Physician's  Note  Book 

ON 

The  Early  Diagnosis  of 
Pulmonary  Tuberculosis 


Bureau  of  Tuberculosis 

California  State  Board  of  Health 


California 

State  Printing  Office 

1916 


PUBUC 
HEALTH 


This  pamphlet  has  been  prepared  at  the  request 
of  a  number  of  physicians.  It  is  the  doctor  who 
recognizes  the  incipient  case  of  tuberculosis,  who 
holds  the  key  to  the  solving  of  this  most  serious  of 
all  diseases.  The  records  returned  from  the  county 
hospitals  show  many  times  an  early  history  of 
malaria,  which  undoubtedly  was  inci^lient  tubercu- 
losis. 

The  Bureau  of  Tuberculosis  is  indebted  to  Dr. 
Robert  A.  Peers,  of  the  California  State  Board  of 
Health,  and  Dr.  William  P.  Lucas,  of  the  Medical 
College,  University  of  California,  for  the  text  of  this 
book. 


TNE  EARLY  DIAGNOSIS  OF  PULMONARY  TUBERCULOSIS. 

By  Robert  A.   P^ers,  M.D.,  Colfax, 
Member    California    State    Board   of   Health. 

The  experience  of  anti-tuberculosis  workers  in  the 
past  has  been  that  one  of  the  most  discouraging  things 
to  be  contended  with  is  that  a  majority  of  patients  do 
not  come  under  observation  or  apply  for  treatment  until 
the  disease  has  progressed  to  such  a  stage  as  to  render 
a  cure  doubtful.  Even  if  there  is  a  good  outlook  for 
improvement,  the  late  stage  of  the  disease  means  many 
months  or  years  of  invalidism  or  semi-invalidism  with 
the  attendant  loss  of  time  and  money,  to  say  nothing  of 
the  thwarted  ambitions  or  physical  sufferings  of  the 
patient.  Many  diseases  are  self-limited  and  run  a  certain 
course  or  take  a  certain  length  of  time  irrespective  of 
whether  discovered  early  or  late.  Tuberculosis,  on  the 
other  hand,  is  a  disease  in  which  early  discovery  is  prac- 
tically all  important.  Usually  the  earlier  the  diagnosis, 
the  shorter  the  period  of  forced  inactivity.  One  month 
saved  in  the  making  of  a  diagnosis  and  the  commence- 
ment of  treatment  may  mean  an  arrest  of  the  disease  many 
months  earlier  than  if  discovered  later.  It  may  mean 
the  difference  between  death  and  recovery.  Many  cases 
of  tuberculosis  should  be  diagnosed  as  such  months 
before  the  correct  diagnosis  is  really  made.  This  is 
not  infrequently  the  fault  of  the  patient.  Through  igno- 
rance of  the  importance  and  significance  of  his  symptoms 
he  frequently  does  not  apply  for  relief  until  already  in 
an  advanced  stage.  Frequently  he  may  be  the  victim 
of  self-medication,  taking  cough  medicines  and  tonics 
until  so  ill  that  relief  can  be  merely  palliative.  The 
Bureau  of  Tuberculosis  is  endeavoring  to  reach  this 
class  of  patients  by  education  of  the  masses.  It  is  to 
be  regretted  that  only  too  frequently  the  fault  lies  with 
the    members    of    the    medical    profession.     The    early 

22766 

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diagnosis  of  tuberculosis  is  not  always  an  easy  matter; 
frequently  it  is  one  of  great  difficulty.  The  Director  of 
the  Bureau  of  Tuberculosis  felt  that  it  might  be  of  bene- 
fit and  aid  in  securing  of  earlier  diagnoses  if  the  members 
of  the  medical  profession  were  each  presented  with 
the  following  brochure  which  will  call  attention  to 
some  of  the  aids  in  making  a  diagnosis  of  tuberculosis 
in  adults  and  children.  As  most  cases  of  tuberculosis 
in  adults  assume  the  pulmonary  type,  the  remarks  under 
this  heading  will  deal  with  the  diagnosis  of  pulmonary 
tuberculosis. 

At  this  time  it  might  be  well  to  call  attention  to  a 
few  general  facts  regarding  tuberculosis  under  the  fol- 
lowing headings  : 

(1)  Prevalence. 

(2)  Resemblance  to  other  diseases. 

(3)  Danger  signals. 

(1)  It  is  estimated,  and  with  good  reason,  that  nearly 
every  human  being,  in  countries  where  tuberculosis  is 
prevalent,  at  some  time  becomes  infected  with  pulmonary 
tuberculosis.  Only  a  percentage  of  those  infected,  how- 
ever, develop  the  disease.  Unfortunately,  it  is  not  pos- 
sible to  know  the  time  of  infection  of  any  particular 
individual  nor  to  determine  who  will,  or  who  will  not, 
develop  the  disease  sufficiently  to  require  treatment. 

Because  of  these  facts,  it  is  necessary  to  consider  each 
individual  a  potentially  tuberculous  person  and  to  bear 
this  in  mind  in  the  diagnosis  of  our  own  patients.  In 
addition,  we  do  know  that  one  death  in  seven  in  our 
State  is  due  to  tuberculosis.  Thus  each  physician  can 
be  certain  that,  if  the  present  death  rate  is  maintained, 
one  in  seven  of  his  clients  will  die  from  tuberculosis, 
while  an  even  higher  percentage  of  those  seeking  relief 
at  his  hands  will  be  suffering  from  this  disease.  These 
facts,  therefore,  should  be  borne  in  mind  whenever  mak- 
ing a  diagnosis  of  a  medical  case  or  of  a  surgical  case 
wherein  tuberculosis  is  a  possibility. 


(2)  Now,  as  to  a  number  of  diseases  which  have 
symptoms  similar  to  those  frequently  observed  in  tuber- 
culosis and  with  which  tuberculosis  is  sometimes  con- 
fused. The  principal  ones  are  malaria,  typhoid  fever, 
chronic  bronchitis,  unresolved  pneumonia,  asthma  and 
la  grippe. 

Malaria : 

In  the  early  stages  of  tuberculosis,  when  the  disease 
is  not  extremely  acute,  there  is  often  present  a  symptom 
complex  which  is  not  at  all  dissimilar  to  malaria.  There 
is  the  same  lassitude  and  loss  of  ambition,  headache, 
tendency  to  tire  easily,  a  feverishness,  especially  in  the 
afternoon,  and,  in  many  cases  chilliness  or  even  definite 
chills.  When  the  chill  and  fever  occurring  in  the  after-' 
noon  are  followed  by  sweating  at  night  the  diagnosis 
is  even  more  obscured.  The  lack  of  the  presence  of 
Plasmodia  in  the  blood,  the  failure  of  the  symptoms  to 
clear  up  under  quinine  treatment,  and  the  careful  taking 
of  a  history  and  a  painstaking  examination  should  enable 
us  to  rule  out  malaria  and  reach  the  proper  decision  if 
the  patient  is  tuberculous. 

Typhoid  Fever: 

Not  a  few  cases  of  tuberculosis  of  the  acute  type 
simulate  very  closely  typhoid  fever.  Here  the  absence 
of  a  positive  widal  reaction  or  a  negative  blood  culture 
for  the  bacillus  typhosus  should  put  us  on  our  guard. 
Again,  a  careful  history  followed  by  a  closely  observed 
and  well-kept  clinical  chart  will  be  of  great  aid.  The 
pulse  rate  in  tuberculosis  is  more  rapid  than  in  typhoid, 
the  temperature  is  more  irregular,  there  is  absence  of 
the  laboratory  findings  seen  in  typhoid  cases  and  there 
is  not  the  usual  typhoid  convalescence.  In  these  cases, 
and  likewise  in  those  simulating  malaria,  there  is  almost 
always  a  daily  cough,  very  slight  maybe  and  limited  to  a 
morning  clearing  of  the  throat,  but  still  sufficient  to  help 

2—22766  3 


US  to  arrive  at  a  diagnosis.  The  X-ray,  tuberculin  tests 
and  laboratory  examination  of  the  sputum  will  all  be  of 
aid,  but  too  much  reliance  must  not  be  placed  upon 
them  to  the  exclusion  of  other  evidence.  This  is  par- 
ticularly true  of  the  X-ray  and  of  tuberculin  tests  which 
should  be  interpreted  by  experts.  The  one  thing  to 
remember  above  all  others  is  that  a  negative  sputum 
does  not  mean  that  the  patient  has  not  tuberculosis. 
.When  tubercle  bacilli  are  present  in  the  sputum,  their 
presence  indicates  tuberculosis  somewhere  in  the  respir- 
atory tract.  Their  absence  from  the  sputum  means 
nothing  more  than  that  they  were  not  found  on  the 
slides  examined. 

Nevertheless,  whenever  there  is  any  sputum  to  be 
obtained  it  should  be  very  thoroughly  and  carefully 
examined  for  tubercle  bacilli.  A  failure  to  have  the 
sputum  examined  when  patients  expectorate  is  a  breach 
of  trust  on  the  part  of  the  physician. 

Chronic  bronchitis,  unresolved  pneumonia,  asthma  and 
chronic  la  grippe  are  all  diseases  which  exist  and  with 
which  we  will  come  in  contact.  Experience  has  shown, 
however,  that  the  majority  of  cases  of  chronic  bronchitis 
are  in  reality  cases  of  tuberculosis ;  that  pneumonias  fail 
to  resolve  usually  because  there  is  an  underlying  tuber- 
culosis ;  that  many  cases  diagnosed  as  asthmatic  are  not 
asthmatic  but  that  the  dyspnoea  and  violent  coughing 
attacks  are  due  to  tuberculosis  (especially  is  the  latter 
true  where  extensive  disease  or  extensive  fibrosis  have 
so  distorted  the  bronchi  as  to  render  difficult  the  expecto- 
ration of  sputum)  ;  chronic  la  grippe  is  almost  always 
tuberculosis.  The  diagnosis  in  these  cases  can  be  cleared 
up  often  only  after  a  thorough  history  has  been  taken; 
after  the  patient  has  been  carefully  watched  for  days  or 
weeks ;  only  after  many  examinations  and  by  calling  to 
our  assistance  every  laboratory  aid.  These  the  patient 
is  entitled  to,  and  the  physician  will  find  that  the  results 
obtained  amply  repay  him  for  his  trouble. 


(3)  There  are  many  danger  signals  which  are  very 
common  in  tuberculosis  and  which  should  cause  the 
physician  to  think  of  the  possible  existence  of  this 
disease.  Some  of  them  appear  quite  early  while  others 
appear  later.  Lack  of  space  will  allow  merely  an 
enumeration  of  the  principal  of  these.  The  enumera- 
tion is  not  in  the  order  of  their  importance,  nor  of  their 
appearance : 

(1)  A  tendency  to  tire  easily,  especially  in  the  after- 
noon when  formerly  there  has  been  no  fatigue  doing 
work  of  a  similar  character. 

(2)  A  tendency  to  slight  and  irregular  temperature, 
especially  in  the  afternoon.  A  temperature  of  99.2,  99.4 
or  99.6,  occurring  frequently,  is  very  strong  evidence  of 
a  chronic  toxemia.  The  most  common  toxemia  is  a 
tuberculosis  toxemia. 

(3)  A  steady  loss  of  weight  when  this  can  not  be 
explained  by  changes  in  diet  or  character  of  work,  or 
in  other  ways. 

(4)  The  presence  of  a  chronic  cough  or  clearing  of  the 
throat,  especially  in  the  morning,  after  laughing,  loud 
talking,  or  singing.  This  combined  with  1,  2  and  3  is 
very  suspicious,  and  such  a  patient  should  be  considered 
suffering  from  tuberculosis  until  proved  free  from  that 
disease. 

(5)  Likewise,  spitting  of  blood  should  be  considered 
a  sign  of  tuberculosis  unless  proved  otherwise. 

(6)  Attacks  of  pleurisy,  unless  in  conjunction  with  a 
definite  pneumonia,  or  following  an  injury  to  the  chest 
wall,  or  in  other" cases  when  the  cause  is  definitely  shown 
to  be  other  than  the  tubercle  bacillus,  should  be  con- 
sidered as  tuberculous.     Pleurisy  with  a  serious  effusion 

■  is  practically  always  of  tuberculous  origin. 

(7)  The  presence  of  night  sweats  is  very  significant 
and  while  usually  seen  in  advanced  cases,  is  not  infre- 
quently seen  in  the  early  stages. 

(8)  A  rapid  pulse  without  sign  of  cardiac  disease  is 
very    frequently,    almost    always    found    even    in    early 


tuberculosis.  This  is  shown  especially  after  slight 
exercise  when  there  is  very  likely  to  be  slight  dyspnoea 
also. 

There  has  been  no  attempt  to  outline  in  this  booklet 
a  method  of  examination  nor  of  history  taking.  These 
can  be  found  in  the  textbooks  on  the  shelves  of  every 
physician.  There  is  no  royal  road  to  a  diagnosis  and  no 
short  cuts  to  be  made.  A  diagnosis  must  be  made  upon 
the  history,  the  symptoms,  the  findings  at  examination, 
and  the  laboratory  reports.  Study  and  experience  alone 
will  enable  us  to  assign  to  each  of  these  its  proper  rela- 
tive position  in  regard  to  importance  in  each  case.  The 
physician  must  also  be  willing  to  take  time  to  secure 
histories  of  his  caseS;,  he  must  take  the  time  to  examine 
his  patient,  and  he  must  be  able  to  interpret  what  he 
finds.  He  must  not  make  a  diagnosis  on  any  one 
symptom  or  finding  unless  it  is  the  discovery  of  tubercle 
bacilli  in  the  sputum,  but  must  study  and  correlate  all 
the  findings  in  order  to  arrive  at  the  proper  conclusion. 


TUBERCULOSIS  IN  INFANCY  AND  CHILDHOOD. 

William   Palmi:r  I^ucas,   M.D. 
Professor  of  Pediatrics,  University  of  California. 

The  more  the  subject  of  tuberculosis  is  studied  the 
more  certain  it  seems  that  a  clear  definition  should  be 
made  between  infection  and  disease.  When  we  see 
statistics  stating  that  80  per  cent  to  90  per  cent  of  chil- 
dren have  tuberculosis  by  the  time  they  are  14  years 
of  age  this  must  mean  tuberculous  infection  and  not 
tuberculous  disease.  We  know  that  infection  is  very 
prevalent  in  children,  but  infection  fortunately  does  not 
mean  disease.  It  simply  means  that  somewhere  the 
tubercle  bacilli  have  gained  entrance  and  have  found  a 
definite  lodging  place,  usually  in  some  group  of  glands, 
as  the  cervical  or  bronchial  glands.  Here  the  tubercle 
bacilli  may  remain  dormant  for  years  producing  no 
symptoms  nor  any  general  systemic  reactions. 

The  Von  Pirquet  reaction  merely  shows  the  presence 
of  infection.  It  does  not  necessarily  mean  disease. 
This  is  a  very  important  point  to  have  in  mind  when 
considering  the  value  of  the  Von  Pirquet  reaction. 

Tuberculous  disease  has  varying  manifestations,  de- 
pending on  the  age  of  the  child.  Infection  in  the  first 
year  very  often  leads  to  disease.  Statistics  show  that 
about  80  per  cent  of  the  children  who  are  infected  in  the 
first  year  of  life,  sooner  or  later  have  the  disease,  and  a 
large  percentage  of  these  die,  either  from  general  mili- 
ary tuberculosis  or  from  miliary  tuberculosis  and  tuber- 
cular meningitis  as  an  accompanying  manifestation  of  the 
widespread  tuberculous  process.  Tuberculous  disease  in 
the  first  two  years  is  a  very  serious  and  fatal  condition. 
Fortunately  it  is  easier  to  limit  infection  during  these 
first  two  years  than  later  because  contact  with  tuber- 
culous   individuals    can    be    definitely    regulated    during. 

;;7 


this  period,  as  all  infants  should  nurse,  or  if  they  have 
milk,  should  have  certified  milk,  and  the  two  main 
sources  of  infection,  contact  and  infected  milk,  can  be 
easily  controlled. 

The  symptoms  of  tuberculous  disease  in  infancy  are 
often  very  difficult  to  determine.  They  usually  have  to 
do  with  loss  of  appetite  or  loss  in  weight,  and  no  definite 
localizing  symptoms  until  very  late,  when  in  a  large 
proportion  of  cases  of  miliary  tuberculosis  meningeal 
symptoms  appear.  If  the  infection  starts  from  perito- 
neal glands  we  have  symptoms  pointing  to  the  abdomen 
and  intestinal  tract,  with  diarrhea  and  frequent  digestive 
disturbances,  with  increased  size  of  the  abdomen.  In 
these  cases,  either  the  massive  glands  can  be  felt  or  the 
presence  of  fluid  can  be  easily  determined. 

If  the  disease  manifests  itself  during  infancy  in  the 
bony  system,  the  prognosis  is  very  much  better.  Here 
we  find  dactylitis  and  occasionally  involvement  of  the 
hip  joint  toward  the  end  of  the  second  year. 

Involvement  of  the  cervical  glands,  infection  coming 
through  the  tonsils  and  adenoids,  is  not  as  frequent 
during  infancy  as  it  is  during  early  childhood,  though 
during  the  second  year  we  see  it  not  infrequently. 
From  the  standpoint  of  disability  and  mortality  this 
probably  is  the  most  hopeful  type  of  tuberculous  disease 
met  with  in  infancy,  as  properly  treated  it  can  be  kept 
localized,  and  if  necessary  the  glands  can  be  completely 
removed  though  this  is  not  always  indicated. 

Tuberculous  disease  in  childhood  (from  2  to  14  years) 
has  a  varying  symptom  complex.  Usually  we  can  elicit 
a  history  of  exposure  in  the  home,  probably  through 
some  member  of  the  family  or  a  caretaker  or  an  indi- 
vidual who  has  had  frequent  and  direct  contact  with 
the   child. 

Infection  which  develops  into  disease  is  rarely  gained 
from  street  contact;  undoubtedly  a  good  deal  of  infec- 
tion is  so  developed,  but  these  are  usually  so  timed  that 
the    child    develops    enough    immunity   not   to   have   it 


progress  into  a  diseased  condition,  and  we  may  feel 
fairly  confident  that  where  a  child  develops  tuberculous 
disease  it  has  been  brought  into  frequent  contact  with 
a  tuberculous  individual  or  has  repeatedly  taken  infected 
milk. 

Certain  diseases  are  most  important,  both  in  infancy 
and  childhood,  as  being  predisposing  causes  for  the 
development  of  tuberculous  disease.  We  consider 
whooping-cough  and  measles  as  definite  predisposing 
factors  in  tuberculous  disease.  This  presupposes  the 
presence  of  tuberculous  infection  either  previous  to 
whooping-cough  or  measles,  or  very  shortly  following. 
These  diseases  lower  the  resistance  of  the  child  to 
tuberculous  disease.  The  danger  from  these  infectious 
diseases,  and  others  that  involve  the  respiratory  tract, 
or  for  that  matter  any  prolonged  infection  that  lowers 
the  resistance  of  the  child,  is  that  it  becomes  more  pos- 
sible for  the  tuberculous  infection  to  develop  into  tuber- 
culous disease.  This  is  the  main  reason  why  the  recog- 
nition of  infection  is  so  important  and  the  prevention 
of  any  infectious  diseases  becomes  more  important 
in  infants  and  children  who  have  tuberculous  infections. 

The  diagnosis  of  tuberculous  disease  in  childhood  is 
either  very  easy  or  very  difficult  to  make.  It  is  easy 
when  the  history  of  exposure  is  definite  and  where  the 
physical  findings  are  clear  cut,  such  as  we  get  in 
tuberculous  disease  of  the  bony  system,  as  Potts'  disease, 
or  tuberculosis  of  the  hip  or  tuberculous  peritonitis, 
but  it  is  often  very  difficult  to  make  a  definite  diagnosis 
of  tuberculous  disease  where  the  symptoms  are  not 
localized.  In  such  cases,  persistent  loss  of  weight  or 
failure  to  gain  consistently,  listlessness,  easy  fatigue,  loss 
of  appetite  or  irritability  are  further  suggestive 
symptoms.  A  tendency  to  repeated  colds  or  bronchitis, 
with  or  without  night  sweats,  is  not  infrequently  present. 

The  examination  of  such  children  would  show  a  very 
irregular  temperature,  sometimes  elevated  in  the  morn- 
ing, sometimes  at  night  and  sometimes  continuous.     The 


main  characteristic  of  the  temperature  is  this  irregu- 
larity, usually  above  99°,  not  often  running  over  100° 
or  101  °  unless  the  symptoms  are  pronounced.  The  pulse 
is  usually  rapid,  in  fact  vaso-motor  changes  are  often 
a  pronounced  feature.  The  child  will  flush  easily  or 
pale  easily  and  at  other  times  be  normal.  A  moderate 
amount  of  anemia  with  pallor  is  usually  present,  the 
blood  showing  a  picture  of  moderate  secondary  anemia. 
The  digestive  symptoms,  in  addition  to  the  loss  of 
appetite,  are  demonstrated  by  attacks  of  intestinal  indi-. 
gestion  either  accompanied  by  diarrhea  or  constipation, 
and  the  child  has  a  coated  tongue. 

Repeated  physical  examinations  of  the  chest  usually 
give  certain  definite  persisting  signs.  Over  the  area  of 
the  bronchial  glands  there  is  definite  resistance,  paraver- 
tebral dullness  is  definite.  D'Espine's  sign  in  children 
old  enough  to  whisper,  is  present  as  far  down  as  the 
fifth  or  sixth  dorsal  vertebra.  Often  there  are  definite 
areas,  either  at  the  apex  or  base  on  one  or  both  sides 
where  there  are  persistent  slight  changes,  and  the 
presence  of  fine  rales  over  a  limited  area  found  on 
repeated  examinations  are  very  suggestive.  Increased 
vocal  and  tactile  fremitus  in  the  neighborhood  of 
enlarged  glands  is  common.  Enlarged  thoracic  veins 
from  pressure  by  these  enlarged  glands  is  not  as  fre- 
quent a  finding  as  one  would  expect. 

The  X-ray  findings  in  such  cases  are  always  most 
helpful  and  illuminating.  The  extent  of  the  process  as 
shown  by  the  X-ray  is  usually  more  extensive  than  that 
brought  out  by  our  physical  examination,  and  in  the 
presence  of  a  strongly  positive  tuberculin  test,  it  is 
safe  in  this  large  group  of  indefinitely  diseased  children 
to  make  a  positive  diagnosis   of  tuberculous   disease. 

The  sputum  is  rarely  obtainable  in  children,  though  in 
older  children,  by  taking  throat  swabs,  these  very  often 
will  bring  up  thick  mucus  secretion  in  which  the  tubercle 
bacilli  are  easily  demonstrated  when  there  is  no  sputum 
at  all. 

10 


It  must  not  be  forgotten,  however,  that  most  of  these 
symptoms  can  arise  from  other  conditions,  but  when 
they  exist  a  very  careful  study  of  each  case  should  be 
made  before  we  are  justified  in  ruling  out  tuberculous 
disease. 

The  treatment  of  tuberculosis  in  infants  and  children 
necessarily  varies  with  age,  with  the  extent  and  severity 
of  the  infection  and  with  the  localization  of  the  disease. 
If  it  is  general,  as  it  usually  is  in  early  infancy,  very 
little  can  be  done  by  treatment. 

The  main  reduction  in  mortality  during  infancy  must 
depend  upon  the  prevention  of  infection,  not  on  the  hope 
of  bringing  about  a  cure,  because  the  resistance  to  tuber- 
culosis in  infancy  is  very  low  and  hard  to  develop.  The 
older  a  child  gets,  the  more  hopeful  is  treatment  if  the 
condition  is  recognized  early. 

The  treatment  of  tuberculous  disease  of  any  organ,, 
of  course,  must  depend  on  what  organ  is  involved. 
Usually  the  disease  in  childhood  is  prolonged,  at  first 
being  very  insidious ;  even  when  definitely  localized  in 
the  bony  system,  or  in  the  kidneys  or  glandular  system,, 
its  course  is  a  prolonged  one. 

Three  important  points  to  be  observed  in  treatment 
are :  first  the  conservation  of  energy.  This  means  that 
the  child  must  be  kept  quiet,  must  not  be  allowed  to- 
become  fatigued,  which  is  often  one  of  the  prominent 
symptoms  of  the  disease,  the  child  becoming  irritable 
on  account  of  its  fatigue.  It  is  often  striking  to  note 
how  the  appetite  and  general  resistance  of  a  child  will 
improve  with  a  definite  daily  regime  which  conserves 
to  the  utmost  the  child's  energies  and  prevents  over- 
exertion or  excessive  stimulation,  so  that  quiet  is  also 
a  necessary  factor  in  this  first  phase  of  the  treatment. 

The  second  important  consideration  is  diet.  This 
should  be  one  which  the  child  can  easily  digest.  It  is 
wise  to  remember  that  forcing  food,  especially  food 
rich  in  fat,  may  cause  definite  intestinal  indigestion 
because  the  digestion  of  fats  is  definitely  diminished  in 


tuberculosis,  especially  tuberculosis  of  the  intestinal  tract. 
It  is  remarkable  how,  often  when  the  child  has  had  no 
appetite,  simply  putting  it  to  rest  in  a  quiet,  congenial 
atmosphere  with  all  friction  and  excessive  stimulation 
removed,  the  appetite  will  improve  without  giving  any 
medication.  Iron  assists  in  bringing  the  muscular  tone 
of  the  child  as  well  as  its  appetite  to  a  better  condition. 
The  digestive  capacity  of  the  child  should  be  carefully 
watched  in  order  that  derangement  may  not  be  caused. 

Third,  a  most  important  point  in  the  treatment  is 
fresh  air  and  sunlight.  The  child  should  be  out  of  doors 
as  much  as  possible  while  awake  as  well  as  when  at 
rest.  The  value  of  sun  baths  has  been  clearly  demon- 
strated. Sun  rays  have  not  only  a  marked  tonic  effect 
but  undoubtedly  stimulate  definite  reactions  in  the  body, 
especially  in  the  bony  and  glandular  systems,  and  as 
these  two  systems  are  the  most  often  involved  in  child- 
hood the  application  of  sun  rays  becomes  most  important. 
This  form  of  treatment  should  be  carefully  supervised, 
however,  as  over  stimulation  may  do  more  harm  than 
good.  Carefully  increasing  the  dosage  of  sunlight,  not 
only  to  the  infected  area  but  exposing  the  child  stripped 
both  front  and  back  to  the  direct  sun  rays,  protecting 
it  while  taking  the  sun  bath  from  the  wind,  is  a  very 
important  feature  of  outdoor  treatment.  This  is  a  form 
of  treatment  which  should  be  used  in  this  State  much 
more  than  it  is. 

Tuberculin  treatment  is  of  some  value  both  in  gland- 
ular and  bony  tuberculosis  in  children.  It  is,  of  course, 
of  no  value  in  generalized  tuberculosis  in  infants, 
and  it  is  only  of  value  where  it  is  very  carefully  and 
intelligently  administered.  There  can  be  no  rules  laid 
down  as  to  its  administration;  each  case  must  be  con- 
sidered separately.  Certainly  it  should  not  be  given  in 
such  dosage  as  to  cause  marked  reactions.  That  amount 
should  be  given  which  simply  stimulates  production  of 
immunity,  but  does  not  cause  any  marked  constitutional 
reactions. 


<SllWlii>ilBBliiMftJiLMi|iim.,  Lx 


T*^ 


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